No short-term guarantees with Dwight Howard's back injury

CLEVELAND — The NBA playoffs are scheduled to begin on April 28, but the Orlando Magic do not know if their superstar will play, or be able to play effectively, by then.

With Dwight Howard's injury — a herniated disk in his lower back that has caused painful, persistent back spasms — there are no short-term guarantees.

"It's a challenging issue while an athlete is trying to perform at a high level, and symptoms can change hourly," said Ralph Reiff, an athletic trainer and the executive director of St. Vincent Sports Performance in Indianapolis.

Magic officials continue to say that no timetable has been set for Howard's return. They say Howard's return date will depend on how he responds to treatment.

Physician Andrew Hecht, chief of spinal surgery at Mount Sinai Medical Center in Manhattan and a consultant to the New York Jets and the New York Islanders, said an athlete suffering from a herniated disk typically will begin with a conservative, nonsurgical course of treatment.

Disks sit between each spinal vertebra and function as shock absorbers and cushions. The disks consist of a gel-like interior surrounded by a tough exterior.

Problems arise when the gel either pushes against the wall of the disk or when the gel seeps through the wall of the disk. In those cases, pressure is put on surrounding nerves and can lead to pain.

Hecht, who has not examined Howard or seen Howard's MRI, compared a herniated disk to a jelly doughnut in which the jelly is seeping out.

But it is unclear whether Howard's injured disk is fully herniated and leaking or whether the gel inside the disk merely is protruding from the disk.

Both situations can lead to significant pain.

It's also unclear what, exactly, caused the defect in the disk's casing. It could be the result of a one-time incident or the result of years of stress on Howard's back or a combination of years of stress and a preexisting condition such as a pronounced curvature of the spine.

"What typically occurs is that there's a series of events that causes an erosion of the stability of the disk and the ligaments and soft tissue that hold the disk and the vertebrae in place," Reiff said. "So that can be just from repetitive exercise. It can be, in this case, from a tall, linear basketball player who rotates and jumps and flexes and bends multiple times throughout a day and throughout a season and throughout a career."

Howard, who is 26 years old, faces a particularly difficult situation.

Last month, he waived the early-termination clause in his contract, meaning he cannot became a free agent until after the 2012-13 season. Still, his free agency is nearing, and if his injury worsens, it could reduce his value on the free-agent market.

Hecht said the initial treatment for an athlete typically begins with rest, anti-inflammatory drugs and physical therapy.

Howard also could receive an epidural injection in which a steroid is delivered directly to the spot of the herniation in order to reduce inflammation around the nerves.

Hecht said the conservative therapy could take days, weeks or months to work.

In the meantime, the Magic's medical staff likely will treat the symptoms of the herniated disk by using electrical stimulation, ice and heat.

But those would not solve the root problem. Surgery to remove the herniated piece is an option, and the outcome is usually positive, Hecht said.

"If it comes to something like that," Hecht said, "90 percent of the elite athletes will resume their elite level somewhere between 12 and 16 weeks."